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General NPI Number Information
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NPI Number | 1174497721
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Entity Type | Individual
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Provider Name | EBONY CASSANDRA SUDDUTH
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Gender | Female
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Dates
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Enumeration Date | 10/06/2025
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Last Update Date | 10/06/2025
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Provider Practice Location Address
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Address Line | 4801 WELDON SPRING PKWY
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City | WELDON SPRING
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State | MO
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Zip | 63304-9101
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Country | US
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Telephone | 636-441-7300
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Fax |
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Provider Business Mailing Address
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Address Line | 10200 CEDARHURST DR
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City | SAINT LOUIS
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State | MO
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Zip | 63136-5616
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Country | US
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Telephone | 636-628-5801
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 2025041043
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License Number State | MO
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